Question of the Week # 406

406)  A 65 year old woman is evaluated in your office for urinary problems. She reports involuntary loss of urine upon coughing almost daily for few months. She presented with similar problems 6 months ago and has been advised pelvic floor exercises and lifestyle modifications . These measures have not improved her symptoms. She denies any nocturia, frequency, hesitancy or urgency symptoms. She has no other medical problems On examination, vitals are stable. Pelvic examination reveals changes consistent with vaginal atrophy. When she is asked to cough in lithotomy position, there is large urinary leakage about 30 seconds after coughing which was difficult for her to stop. Complete blood count, Plasma glucose, Serum electrolytes and Urinalysis are within normal limits. Which of the following is the most appropriate next step?

A) Start Vaginal Estrogen

B) Recommend Vaginal Pessary

C) Obtain Urodynamic Studies

D) Mid-Urethral Sling  placement

E) Trial of Alpha-Adrenergic Agonists

Question of the Week # 405

405)  A 80 year old woman with advanced dementia is sent to your office for evaluation of a vaginal ulcer. The patient has a history of Stage III uterine prolapse. She had been fitted with a pessary for control of her symptoms about 6 months ago. She has no history of fever or chills. On examination, she is afebrile, blood pressure is 130/80. Pelvic examination revealed complete procidentia with impacted pessary and a 2  x 2 cm ulcer without any exudate. An attempt to remove the pessary is unsuccessful. Biopsies of the ulcer have been obtained. Which of the following is the appropriate initial management?

A) Vaginal Estrogen

B) Oral Antibiotics

C) Surgical removal of Pessary

D) Hysterectomy

E) Admit for parenteral antibiotics

Question of the Week # 404

404)  A 70 year old woman in excellent physical health presents to your office because she has noticed a mass falling out of her vagina for the past one year which is progressively worse. For the past six months, she has difficulty voiding. During voiding, she has to constantly change her position and sometimes, needs to push the mass inside in order to urinate. Lately, voiding has become even more difficult despite all these measures. She has problems with defecation which she describes as having to apply pressure on her vagina in order to completely evacuate her bowel. . She denies any fever or burning  urination.  She has normal bowel movements and has no problems with defecation. She is embarrassed to have sex anymore after having had urinary incontinence during sex. She blames herself for neglecting the mass without seeking medical attention for such a long time. Otherwise, she is in excellent physical health and has no other co-morbidity. She is willing to consider any option including surgery if feasible. On examination, vitals are stable. Pelvic examination revealed a total prolapse with total eversion of the vagina which was oedematous with marked ulceration in the dependent portion of the mass. Which of the following is the appropriate initial management?

A) Obtain Urodynamic studies

B) Biopsy

C) Admit for daily Vaginal packing with estrogen

D) Vaginal estrogen and Pessary

E) Vaginal Hysterectomy

Question of the Week # 403

403)  A 68 year old woman with history of Diabetes mellitus is evaluated in your office during routine follow-up visit. She reports that lately she has been experiencing pressure and bulge in her vaginal area and has a sensation of something falling out of her vagina. She denies any fever, burning, frequency or urgency of urination.  She has normal bowel movements and has no problems with defecation. She is sexually active with her husband and enjoys it. She denies any urinary incontinence even upon coughing or sneezing. On examination, vitals are stable. Pelvic examination reveals changes consistent with vaginal atrophy and a Grade 1 Cystocele.  Which of the following is the most appropriate recommendation?

A) Screen for latent Stress incontinence

B) Observation

C) Pessary

D) Surgery

E) Raloxifene

Question of the Week # 402

402)  A 68 year old woman with history of Diabetes mellitus is evaluated in your office during routine follow-up visit. She reports that lately she has been experiencing pressure and bulge in her vaginal area and has a sensation of something falling out of her vagina. She denies any fever, burning, frequency or urgency of urination.  She has normal bowel movements and has no problems with defecation. On examination, vitals are stable. Pelvic examination reveals changes consistent with vaginal atrophy and presence of moderate cystocele.   She has marked urinary leakage when she was asked to cough in lithotomy position. Complete blood count, Plasma glucose, Serum electrolytes and Urinalysis are within normal limits. She requests information regarding surgery for vaginal prolapse. Which of the following is the most appropriate statement regarding surgery for her cystocele?

A) Surgery may worsen her Incontinence

B) Surgery may increase urinary obstruction

C) If she were to undergo prolapse surgery, no additional incontinence treatment is needed

D) Surgery may cause defecation problems

E) Surgery is optimal option for her at this time.

Question of the Week # 401

401)  A 78 year old woman presents for annual health-maintenance examination. Her medical problems include Hypertension, Diabetes, Coronary artery disease and Chronic obstructive pulmonary disease. During review of systems, she reports that she has been experiencing involuntary loss of urine upon coughing almost daily for few months. She has been too embarrassed to disclose it and so, has not mentioned it during previous visits. However, the problem has been limiting her social activities and she really would like to "do something about it". She denies any nocturia, frequency, hesitancy or urgency symptoms. Her medications include albuterol, ipratropium, glyburide, clopidogrel and losartan. She had a myocardial infarction followed by coronary stent placement six months ago. On examination, vitals are stable. Pelvic examination reveals changes consistent with vaginal atrophy and presence of moderate cystocele.   She has marked urinary leakage when she was asked to cough in lithotomy position. She has tried pelvic floor exercises and scheduled-voiding for past several weeks and has cut down on her coffee consumption however, these measures have not helped her much.  Complete blood count, Plasma glucose, Serum electrolytes and Urinalysis are within normal limits. Which of the following is the most appropriate recommendation for this patient?

A) Check Post-Void Residual volume

B) Vaginal Estrogen

C) Pessary

D) Mid-Urethral Sling placement

E) Oxybutynin

Question of the Week # 400

400)  A 28 year old woman with history of depression is brought to the emergency room by her friend after she purposefully took large number of acetaminophen tablets. Her friend can not estimate how many tablets she took but she says there were at least fifty extra strength tablets in the bottle and the bottle was found empty when she went to visit her. She last spoke with her 18  hours ago over the phone when she sounded very depressed. So, her friend reports she probably must have ingested these tablets at least  12 to 18 hrs ago. On examination, she is drowsy but arousable. Her liver function tests are within normal limits and an acetaminophen level is 15µg/ml . Serum electrolytes, creatinine , prothrombin time and INR are within normal limits. Which of the following is the initial step in management

A) Hemo-Dialysis

B) Supportive care with strict monitoring of Liver function, Creatinine and INR

C) Activated Charcoal

D) N-Acetyl Cysteine

E) Consult Liver Transplant expert

Question of the Week # 399

399)  A 65 year old man with history of diabetes mellitus is evaluated in your office during a routine follow-up visit. He does not have any complaints. He uses Glyburide and Metformin for his diabetes and Atorvastatin 80mg/day and Omega-3 Fatty Acids  for his dyslipidemia. He is compliant with diet and exercise. His weight has been stable. He does not smoke or consume alcohol. His most recent HgbA1C was 6.0% and a fasting lipid panel a month ago showed Total cholesterol of 125 mg%, LDL-C 70mg%, Triglycerides 100mg% and HDL-C 35mg%. You discuss with him that his lipid panel meets the recommendations with regard to LDL cholesterol and Non-HDL cholesterol goals. However, he insists that he be treated for his low HDL-cholesterol. You offer adding Niacin but after he heard about it's side effects he refuses it and seeks alternatives.  Which of the following is the most appropriate recommendation for him?

A) Change Atorvastatin to Rosuvastatin

B) Add Cholestyramine

C) No further therapy

D) Discontinue Omega-3 Fatty Acids

E) Increase Atorvastatin

Question of the Week # 398

398)  A 45 year old man with well-controlled diabetes presents to your office with complaints of troublesome flushing of his face and trunk for the past one week. Frequently, the flushing is severe and causes stinging sensations. His past medical history is significant for dyslipidemia with an isolated low HDL cholesterol for which he was started on Niacin one week ago. On examination, his blood pressure is 120/88 mm Hg.  His face and trunk have flushed appearance. Reminder of physical examination is unremarkable. Which of the following is the most appropriate recommendation for him at this time?

A) Discontinue Niacin

B) Take Niacin with food

C) Diphenhydramine as needed

D) Take Aspirin before Niacin

E) Re-assure symptoms will bate in one week

Question of the Week # 397

397)  A 65 year old man with past medical history of Hypertension presents to your office to discuss his lipid profile results which were obtained two weeks ago.  He takes Losartan for his high blood pressure and is compliant with 2gm sodium diet. He smoked about 1 pack per day for the past 35 years. On examination, his blood pressure is 140/88 mm Hg. Reminder of physical examination is unremarkable. His fasting lipid panel reveals Total cholesterol 220 mg%, LDL-C 150mg%, Triglycerides 150mg%, HDL-C 40mg%. Which of the following is the most appropriate initial step?

A) Diet and lifestyle modifications alone

B) Diet, Lifestyle modification and Statin therapy

C) No Intervention

D) Omega 3 Fatty Acids

E) Repeat Lipid Panel in 3 months

Question of the Week # 396

396)  A 45 year old woman presents to your office for annual physical examination. She reports that she has had a fasting lipid panel done 6 months ago and her HDL - C was low at 25 mg%. She requests to be treated for this. She started healthy diet rich in fruits and vegetables. She used to smoke about 4 cigarettes/ day earlier but quit smoking after she came to know about her lipid results. She occasionally uses red wine in moderate amounts. She has also started aerobic exercises at least 3 days per week. Physical examination is unremarkable. A repeat lipid panel reveals Total cholesterol 128 mg%, LDL-C 80mg%, Triglycerides 100mg%, HDL-C 28mg%. Which of the following is the most appropriate next step?

A) Fenofibrate

B) Niacin

C) Ezetemibe

D) Atorvastatin

E) Omega-3-Fatty Acids

Question of the Week # 395

395)  A 65 year old man with history of Hypertension, Peripheral Artery disease and Dyslipidemia is seen during a follow-up office visit. His medications include Atorvastatin 80mg, Enalapril 20mg and Clopidogrel 75 mg/ day.  He does not have any new complaints and tolerating his medications well. He still smokes about 1 pack per day despite repeated counselling however, he has been strictly compliant with low-fat diet. On examination, his vitals are stable. Lower extremity dorsalis pedis are slightly diminished bilaterally. Reminder of the examination is unremarkable. A fasting lipid profile obtained a week ago showed :  Total Cholesterol : 205 mg% LDL cholesterol (calculated) 90mg%, HDL - cholesterol 45 mg%, Triglycerides 350mg%.  Liver function tests , Serum electrolytes, Creatinine and Complete blood count are within normal limits. Which of the following is the most appropriate next step?

A) Add Fenofibrate

B) Add Niacin

C) Add Cholestyramine

D) Change Atorvastatin to Rosuvastatin

E) Increase the dose of Atorvastatin

Question of the Week # 394

394)  A 36 year old woman with Type I diabetes mellitus presents to your office because she just learned that she is pregnant. She is excited and seeks your advise. Her home blood sugars are well controlled on a basal-bolus regimen of Glargine and Lispro insulin. Her other medications include Atorvastatin and aspirin. Her most recent HgbA1C was 6.0%. Her records also reveal that her most recent fasting lipid profile met the therapeutic goals at LDL of 80mg% and Non-HDL cholesterol of 100mg%. On examination, she is comfortable. Vitals are stable and reminder of the examination is unremarkable. An office based serum pregnancy test is positive. A repeat fasting lipid profile reveals Total Cholesterol : 250 mg% LDL cholesterol (calculated) 140mg%, HDL - cholesterol 40 mg%, Triglycerides 350mg%.  Liver function tests , Serum electrolytes, Creatinine and Complete blood count are within normal limitsWhich of the following is the most appropriate next step?

A) Therapeutic Abortion

B) Add Niacin to her Lipid Regimen

C) Discontinue Statin and Start Niacin

D) Discontinue Statin and advise Diet modification alone

E) Increase Atorvastatin

Question of the Week # 393

393)  A 36 year old homeless man is evaluated in the Emergency Room for intermittent fever, cough, night sweats and weight-losss. He also reports having chronic cough with progressively increasing bloody expectoration for the past 1 month. He has lost about 10lbs weight over the past 3 months. He smokes 1 pack per day and has a history of intravenos drug abuse. On examination, he is cachectic.  He is afebrile, Pulse is 84/min, Respiratory rate 18/min, Blood pressure 120/80 mm Hg, Oxygen saturation 98%.  Reminder of the physical examination is unremarkable. Which of the following is the most appropriate initial step in managing this patient?

A) Sputum samples for Acid Fast Bacilli

B) Start Multi-drug therapy for Tuberculosis

C) Obtain a Chest X-ray

D) Tuberculin Skin test

E) Air-Borne Isolation

F) Test for HIV

Question of the Week # 392

392)  A 28 year old woman presents with a history of amenorrhea of about 6 month duration. She does not have any breast discharge, visual deficits or headaches. Her home pregnancy test was negative a week ago. Her past medical history is significant for three missed abortions for which she underwent dilatation and curettage. On examination, her vitals are stable. Body mass index is about 22 . Breast examination is normal with out any discharge.  Serum pregnancy test is negative. A serum Thyroid Stimulating Hormone, Prolactin level and Follicle Stimulating Hormone level are within normal limit.  A trial of medroxyprogesterone and a later trial of estrogen-progesterone combination fails to induce bleeding. Which of the following is the most appropriate next step?

A) Anti-phospholipid Antibodies

B) Hysteroscopy

C) Dehydro-epiandrosterone level

D) Pituitary MRI

E) Ultrasound of Ovaries

Question of the Week # 391

391)  A 26 year old woman is seen in the outpatient clinic for amenorrhea of about 6 months. The patient ah d been on oral contraceptives but discontinued 6 months ago. She reports having regular menstrual cycles prior to  starting oral contraceptives. She denies any excessive stress or physical activity. She does not have any breast discharge, visual deficits or headaches. presents to your office with complaints of change in her menstrual cycles. On examination, her vitals are stable. Body mass index is about 28 . Breast examination is normal with out any discharge. Pelvic exam is normal. Serum pregnancy test is negative. A serum Thyroid Stimulating Hormone, Prolactin level and Follicle Stimulating Hormone level are within normal limit.  The patient is started on  medroxyprogesterone acetate at 10 mg/ day for 10 days and experiences menstrual bleeding a week after stopping progesterone. This patient is at increased risk for which of the following conditions?

A) Visual Deficits

B) Endometrial Cancer

C) Osteoporosis

D) Pituitary Necrosis

E) Vertebral Compression Fractures

Question of the Week # 390

390)  A 28 year old woman has had amenorrhea for the past 4 months. She reports having regular menstrual cycles prior to these episodes. She is sexually active and a home pregnancy test was negative on two occasions over the last one week. She denies any excessive stress or physical activity. She has had headaches almost daily over the past three months. She denies any visual deficits. Her past medical history is significant for schizophrenia for which she is using risperdal for several years with good control of her disease. On examination, her vitals are stable. Body mass index is about 28 . There is milky discharge on breast examination. Pelvic exam is normal. Serum pregnancy test is negative. A serum prolactin level is 30mcg/ml (5 to 20 mcg/L). A serum Thyroid Stimulating Hormone and Follicle Stimulating Hormone level are within normal limit. An MRI of the brain reveals 10 cm lobulated mass in the anterior skull base. Which of the following is the initial step in evaluating this patient?

A) Repeat Prolactin after Serum Dilution

B) Discontinue Risperdal

C) Trans-Sphenoidal Resection of the Tumor

D) Pituitary Irradiation

E) Bromocriptine

Question of the Week # 389

389)  A 26 year old woman is seen in the outpatient clinic for amenorrhea of about 6 months. The patient ah d been on oral contraceptives but discontinued 6 months ago. She reports having regular menstrual cycles prior to  starting oral contraceptives. She denies any excessive stress or physical activity. She does not have any breast discharge, visual deficits or headaches. presents to your office with complaints of change in her menstrual cycles. On examination, her vitals are stable. Body mass index is about 28 . Breast examination is normal with out any discharge. Pelvic exam is normal. Serum pregnancy test is negative. A serum Thyroid Stimulating Hormone, Prolactin level and Follicle Stimulating Hormone level are within normal limit.  The patient is started on  medroxyprogesterone acetate at 10 mg/ day for 10 days and experiences menstrual bleeding a week after stopping progesterone. Which of the following explains her amenorrhea?

A) Past use of Oral Contraceptive Pills

B) Uterine Adhesions

C) Hypothalamic amenorrhea

D) Polycystic Ovarian Syndrome

E) Premature Ovarian Failire

Question of the Week # 388

388)  A 58 year old man with history of  severe depression is brought to the emergency room with altered mental status. He has been on treatment with amitryptyline for depression for many months. He is accompanied by his wife who reports that they had re-filled one month supply of amitryptyline a week ago but today she discovered an empty bottle at his bedside.  He There is no history of fever, nausea, vomiting or diarrhea. There is no evidence of  any witnessed seizure.  On examination, he is disoriented and lethargic. He is afebrile, Pulse is 84/min, Respiratory rate 18/min, Blood pressure 120/80 mm Hg, Oxygen saturation 98%. He does not respond to verbal commands. Gag reflex is present. Respiratory examination is normal with out any wheezing, rhonchi or crepitations. Cardiac examination and abdominal exam is benign. Intravenous Naloxone and Thiamine were administered in the field without any response. An electrocardiogram is normal. Serum electrolytes and complete blood count, finger stick glucose and arterial blood gases are within normal limits. The patient is intubated and is placed on ventilator. Which of the following is the most appropriate next step?

A) Activated Charcoal

B) Procainamide

C) Sodium Biacrbonate

D) Lidocaine

E) Amiodarone

Question of the Week # 387

387)  A 56 year old man with history of depression and hypertension is brought to the Emergency Room by his sister for altered mental status. There is no history of fever, nausea, vomiting or diarrhea. There is no evidence of  any witnessed seizure. She is not aware of what medications he takes. On examination, he is disoriented and lethargic. He is afebrile, Pulse is 84/min, Respiratory rate 18/min, Blood pressure 80/40 mm Hg, Oxygen saturation 98%. He does not respond to verbal commands. Gag reflex is present. Respiratory examination si normal with out any wheezing, rhonchi or crepitations. Cardiac examination and abdominal exam is benign. Intravenous Naloxone and Thiamine were administered in the field without any response. An electrocardiogram is normal. Serum electrolytes and complete blood count, finger stick glucose are within normal limits. Arterial blood gases does not show any acidemia. A urine drug screen reveals:

Cocaine  - Negative

Amphetamines - Negatives

Benzodiazepenes - Positive

Opiates - Negative

Cannabis - Negative

Tricyclic Anti-Depressants - positive

A suction of his airway and central line are placed and he is started on intravenous fluids. His systolic blood pressure remains in 70 to 80 mm Hg range

Which of the following is the most appropriate next step?

A) Activated Charcoal

B) Intravenous Flumazenil

C) Serum Alkalinization

D) Start Norepinephrine

E) Intravenous Lidocaine

Question of the Week # 386

386)  A 54 year old man presents to the emergency room with dizziness and intermittent palpitations for the past 12 hours. He denies any syncopal episodes or headache or seizures. He has no significant cardiac history. He was seen in the outpatient clinic one week ago for pneumonia and was started on Moxifloxacin. His other medical problems include hypertension for which he is on enalapril and Gastro-esophageal reflux disease for which he takes esomoprazole.  Physical examination reveals regular heart sounds and no murmurs.  Complete Blood Count and Serum electrolytes are within normal limits. An electrocardiogram is obtained and is shown below:



Which of the following is the most appropriate action at this time?

A) Intravenous Magnesium sulfate

B) Discontinue Moxifloxacin

C) Discontinue Esomoprazole

D) Transvenous Pacing

E) Intravenous Isoproterenol

Question of the Week # 386

386) Question on USPTF AAA SCREENING

Question of the Week # 385

385)  A 74 year old man with advanced dementia is sent from nursing for evaluation of umbilical hernia. He is accompanied by his sister who thought that the bulge looked " ugly" and demanded that he be evaluated for surgery.  The patient has been nursing home bound for the past four years. There is no history of nausea or vomiting. When fed, he eats normally. The patient is not oriented and is unable to give further history. He does not have living will or a power of attorney. On examination, his vitals are stable. He appears comfortable. Abdominal examination showed a palpable bulge in the umbilical area which is reducible. There is no erythema and the patient winces when pressure is applied. There is no rigidity. When tried to explain him about possible surgery, the patient does not comprehend. He is not oriented to place, person or time. Which of the following is the most appropriate action at this time?

A) Do not consent for surgery

B) Obtain Psychiatry evaluation for Capacity assessment

C) Re-Evaluate his competence to make decisions

D) Consent him for surgery

E) Obtain Consent from his sister

Question of the Week # 384

384)  A 55  year old airline pilot presents for a follow-up visit for hypertension. He was diagnosed with hypertension a year ago and has been on treatment with hydrochlorthiazide and lisinopril.  He denies any chest pain, palpitations or shortness of breath on exertion. He has no other significant health issues. His Hemoglobin a1C about 6 months ago was 5.0% . A lipid profile obtained 3 months ago showed a total chlesterol of 270mg% with HDL cholesterol of 34mg%. He  smokes about 1 pack per day but denies any drug or alcohol abuse.  There is no family history of Diabetes or coronary artery disease or abdominal aorta aneurysm. On examination, his blood pressure is 138/74. Cardiac examination shows regular heart sound with no S3 gallop or S4. There are no audible murmurs. Abdominal examination is benign and there are no audible bruits. A complete blood count, comprehensive metabolic panel and urinalysis are unremarkable. A resting electrocardiogram shows changes consistent with left ventricular hypertrophy. He had a colonoscopy five years ago which was normal. Which of the following is indicated at this time?

A) No additional Tests

B) Exercise Stress Test

C) Cardiac catheterization

D) Abdominal Ultrasound for Aortic aneurysm

E) Fecal Occult Blood Testing

Question of the Week # 383

383)  A 38 year old african-american male nurse is evaluated in your office because his blood pressure was found to be elevated when the doctor Employee Health Center checked his blood pressure. He was checked in the Employee Health 3 months ago and at that time, his blood pressure was 146/94 mm Hg and a repeat reading by the same doctor was 148/92 mm Hg  a month ago. He checked his blood pressure at home two times at his home and it was ranging between 120/76 to 124/82.  He does not trust this doctor at his work place so, he decided to come and visit you. He denies any dizziness, chest pain, palpitations or shortness of breath. He does not smoke or does not drink alcohol. Several members in family have history of Hypertension. On examination, his blood pressure is 150/94.  His Body Mass Index is 26kg/m2. Cardiac examination shows regular heart sounds. There are no audible murmurs. An electrocardiogram reveals positive voltage criteria for left ventricular hypertrophy. A subsequent 2D-Echo reveals left ventricular hypertrophy with good ejection fraction at 60% and no valvular problems.  Serum creatinine is 1.0mg% and Urinalysis is normal. A lipid profile has been ordered. Which of the following  is the most appropriate investigation to be ordered next?

A) Exercise Stress Test

B) Ambulatory Blood Pressure Monitoring

C) Hemoglobin A1C

D) Plasma Metanephrines

E) Captopril Renal Scan

Question of the Week # 382

382)  A 36  year old Caucasian man presents for a pre-employment health physical. He denies any health problems in the past. He does not smoke or drink alcohol. He denies drug abuse.  He enjoys good health and has no significant medical issues. He has no family history of Hypertension, Dyslipidemia, Diabetes or coronary artery disease.  On examination, his blood pressure is 118/74. Body Mass Index is 24kg/m2. Cardiac examination shows regular heart sound with no S3 gallop or S4. There are no audible murmurs. Abdominal examination is benign and there are no audible bruits. A complete blood count, comprehensive metabolic panel, urinalysis and urine drug screen are unremarkable. Which of the following is indicated at this time?

A) No additional Tests

B) Serum Total Cholesterol and HDL - cholesterol

C) Hemoglobin A1C

D) Fasting Plasma Glucose

E) Prostate Specific Antigen

Question of the Week # 381

381)  A 32 year old Caucasian man is evaluated in your office for hypertension. He reports that he was first noted to have high blood pressure 6-months ago at which time the reading was 146/92 . At that time, he was asked to follow-up in the office however, he disregarded the advise. Recently, during a pre-employment check-up and again at a community health fair, he was noted to have high blood pressure above 150/90 . He denies any dizziness, chest pain, palpitations or shortness of breath. He does not smoke or does not drink alcohol. His mother was diagnosed with hypertension at 60 years of age and father has had hypertension since the age of 50. He  On examination, his blood pressure is 154/98. Body Mass Index is 24kg/m2. Cardiac examination shows regular heart sound with no S3 gallop or S4. There are no audible murmurs. Abdominal examination is benign and there are no audible bruits. Femoral and radial pulses are normal with out any delay. Ophthalmological examination is normal An electrocardiogram is normal with no evidence of left ventricular hypertrophy. Serum creatinine is 1.0mg% and Urinalysis is normal. Which of the following  is the most appropriate next step in evaluating his Hypertension?

A) Renal Artery Magnetic Resonance Angiography

B) 24 Hour Urinary Metanephrines

C) Plasma Renin Activity- Aldosterone Ratio

D) Ambulatory Blood Pressure monitoring

E) No additional diagnostic work-up

Question of the Week # 379 & 380

379)  A 38  year old man from India presents to out-patient clinic with complaints of abdominal pain and bloating. He also reports having intermittent diarrhea. His symptoms are worse upon eating and have progressively worsened over the past 6 months. He has lost about 6 lbs weight over the same period. He has come to visit his sister in the United States and she forced him to seek medical attention. Upon review of systems, he reports intermittent cough associated with mild shortness of breath and wheezing. His past medical history includes frequent episodes of sinus infections. On examination, he appears comfortable. Chest, Cardiac and Abdominal examination is benign. Chest X-ray is normal. Laboratory investigations are shown below:

WBC : 9.0k/µl

Differential : Neutophils 42%, Lymphocytes 30%, Monocytes 8%, Eosinophils 18%

Hemoglobin 13.5gm%

Platelet count 280k/µl

HIV serology : Negative

Stool for ova and parasites : Negative

Liver function Tests: Normal

Serum Creatinine : 1.0mg%

Urinalysis : normal

Which of the following  is the most likely diagnosis?

A) Chagas Disease

B) Eosinophilic Gastroenteritis

C) Churg Strauss Syndrome

D) Wegener's Granulomatosis

E) Tropical Pulmonary Eosinophilia ( Microfilariasis)

380) Which of the following is the most appropriate next step?

A) Upper GI Endoscopy

B) Pulmonary Function Tests

C) Trypanosoma Cruzi Antibodies

D) Di-ethyl carbazine therapy

E) Anti-Proteinase -3 antibodies ( C-ANCA)

Question of the Week # 378

378)  A 34  year old caucasian woman comes for re-evaluation of her chronic epigastric pain and burning.  She feels bloated and full even after eating small amounts of food. She denies any chest pain or shortness of breath. She failed several courses of treatment with h2-blockers and proton pump inhibitiors. She has had two endoscopies in the past which were normal, most recent endoscopy was three months ago.  There was no evidence of gastric stasis on endoscopies after overnight fast.  She was tested for H.pylori infection in the past and was negative. She denies dysphagia, weightloss, nausea, vomiting, dark colored stools or rectal bleeding. There is no family history of gastric malignancy. She does not smoke or drink alcohol.   A ultrasound of the abdomen did not reveal any evidence of gall stones. Amylase and Lipase levels have been normal on several occassions. She has been anxious and unable to sleep at night.  On examination, she is slightly under-weight for her age. Abdominal examination does not reveal any tenderness or palpable masses. Stool guaiac is negative. A complete blood count as well as comprehensive metabolic panel are normal. Which of the following  is the most appropriate next step?

A) Antidepressants

B) Repeat Endoscopy

C) Recommend to take Antacid therapy as needed

D) Scintigraphic gastric emptying study

E) Observation

Question of the Week # 377

377)  A 42  year old man with no significant past medical is evaluated in your office for complaints of burning epigastric pain in his abdomen for the past 2 months. The pain is worse after eating and it is worse at night. He denies any chest pain or shortness of breath.  He takes over the counter antacids when the pain occurs and that seems to relieve the pain temporarily. He lives in New York City and has never traveled outside the United States.  He denies dysphagia, weightloss, nausea, vomiting, dark colored stools or rectal bleeding. There is no family history of gastric malignancy. He does not smoke or drink alcohol.   On examination, he is athletic. Abdominal examination does not reveal any tenderness or palpable masses. Stool guaiac is negative and complete blood count does not show any anemia. Which of the following  is the most appropriate next step?

A) Obtain Upper GI Endoscopy

B) Obtain H.Pylori Serology by ELISA

C) Start Empiric trial with Omeprazole

D) Reassure because his dyspepsia is functional

E) Obtain H.Pylori Stool Antigen

Question of the Week # 376

376)  A 56  year old Hispanic man with no significant past medical history presents to community health center with complaints of burning pain in his abdomen and bloating for the past 2 months. The pain is more is more in the epigastric area and is worse after eating and it is worse at night. He denies any chest pain or shortness of breath.  He takes over the counter antacids when the pain occurs and that seems to relieve the pain temporarily. He denies dysphagia, weightloss, nausea, vomiting, dark colored stools or rectal bleeding. There is no family history of gastric malignancy. He does not smoke or drink alcohol.   On examination, he is well-built. Abdominal examination does not reveal any tenderness or palpable masses. Stool guaiac is negative and complete blood count does not show any anemia. Which of the following  is the most appropriate next step?

A) H.Pylori antibodies

B) Trial of Proton Pump Inhibitors

C) Empiric therapy for H.Pylori

D) Ultrasound Gall Bladder

E) Endoscopy

Question of the Week # 375

375)  A 65 year old woman is evaluated in your office for weight-loss of 20lbs over the past 6 months. She thinks she has lost weight because she is scared of eating since food causes her to have significant abdominal pain. Pain is particularly worse when she takes a fatty meal and is associated with nausea and early satiety. She has a history of coronary artery disease for which she underwent percutaneous coronary intervention 2 years ago.  She denies any chest pain, palpitations or irregular heart beat. She smoked 1 pack cigarettes per day for the past 40 years. On examination, her vitals are stable. Cardiac and abdominal examination are benign. Stool occult blood is negative. Which of the following is the most likely etiology of her symptoms?

A) Mesenteric vein thrombosis

B) Mesenteric atherosclerosis

C) Gastric Malignancy

D) Cholelithiasis

E) Mesenteric arterial thrombosis

Question of the Week # 373 and 374

373)  A 70 year old woman presents to the emergency room with complaints of abdominal pain for the past one day. The pain is in in lower abdomen and is mild to moderate. It has started suddenly and is persistent. She also reports  having had two episodes of  loose and bloody stools this morning. Her past medical history is significant for coronary artery disease, hypertension and chronic kidney disease. On examination, she is afebrile, blood pressure is 130/80 mm Hg, pulse 90/min and respiratory rate 18/min. Cardiac examination reveals normal and regular heart sounds without murmurs. There is tenderness in the left lower quadrant of the abdomen. There is no rebound tenderness or rigidity. The patient is started on intravenous fluids. Stool studies reveal blood but no leukocytes. Clostridium difficle toxin is negative. Stool cultures are sent. Complete blood count shows White blood cell count at 20,000/µl with left shift. She is started on IV hydration. Which of the following is the most likely diagnosis?

A) Mesenteric Infarction

B) Acute Diverticulitis

C) Acute Mesenteric Ischemia

D) Ischemic Colitis

E) Inflammatory Bowel Disease

374) The patient in the above question undergoes appropriate diagnostic work up and the diagnosis is confirmed. Which of the following is the most appropriate next step in management ?

A) Broad spectrum antibiotics

B) Mesenteric angiography

C) Obtain Surgery Consult

D) Percutaneous Transluminal Angioplasty and Mestenteric stent

E) Start Methylprednisolone and Mesalmaine

Question of the Week # 372

371)  A 65 year old man presents to the Emergency room with complaints of severe abdominal pain that began 30 minutes ago while at rest. He reports diffuse pain that all over his abdomen, the lower back as well as in the flanks. His past medical history is significant for diabetes mellitus and peripheral vascular disease. He denies any abdominal trauma. He smokes about 1 pack cigarettes per day . On examination, he is in severe distress secondary to pain. He is afebrile, blood pressure is 80/40 mm Hg, pulse 120/min and respiratory rate 24/min. Abdomen is mildly distended with mild tenderness and a palpable pulsatile mass. Femoral and dorsalis pedis pulses are diminished.  An electrocardiogram reveals sinus tachycardia. The patient is started on intravenous fluids and is placed on a cardiac monitor. Which of the following  is the most appropriate next step?

A) CT scan of the abdomen

B) Exploratory laporotomy

C) Cardiac enzymes

D) Focused Abdominal Sonography in Trauma ( FAST)

E) Start Insulin Drip.

Question of the Week # 371

371)  A 45 year caucasian man is evaluated in your office prior to surgery for refractory heartburn symptoms. He was diagnosed with Gastro-esophageal reflux disease 2 years ago. Initially, his disease was mild and was responsive to over the counter antacids. He was started on PPI ( proton pump inhibitor trial 6 months ago and has not responded. He switched physicians and tried different brands of proton pump inhibitors with no benefit. An endoscopy was performed a year ago and repeat endoscopy 3 months ago revealed erosions and inflammations consistent with reflux esophagitis with out any background of barrett's esophagus. The patient is scheduled for fundoplication surgery and is here for pre-operative evaluation. Which of the following should be performed at this time ?

A) 24 hour esophageal pH monitoring

B) Barium esophagogram

C) Esophageal motility studies

D) No additional tests needed , clear patient  for surgery

E) H.Pylori Urea Breath Test

Question of the Week # 370

370)  A 47  year old woman presents to your office with complaints of change in her menstrual cycles. Lately, she has had very irregular periods and sometimes, they have been heavy. She reports her cycles have been irregular for past 8 months. Her most recent period was two weeks ago and was much heavier than usual. She also has started experiencing hot flashes. She is not on oral contraceptive pills. She does not smoke or use alcohol. She has no other past medical problems and otherwise, feels healthy. Her family history is unremarkable. Physical examination including pelvic examination is unremarkable. A urine pregnancy test and Thyroid stimulating hormone are within normal limits. Urinalysis is normal. Which of the following is the most appropriate initial step in management?

A) Reassure that she is menopausal transition and observe

B) Obtain Serum FSH level

C) Start Oral Contraceptive Pills

D) Endometrial Biopsy

E) Oral Progestin

Question of the Week # 370

370)  A 47  year old woman presents to your office with complaints of change in her menstrual cycles. Lately, she has had very irregular periods and sometimes, they have been heavy. She reports her cycles have been irregular for past 8 months. Her most recent period was two weeks ago and was much heavier than usual. She also has started experiencing hot flashes. She is not on oral contraceptive pills. She does not smoke or use alcohol. She has no other past medical problems and otherwise, feels healthy. Her family history is unremarkable. Physical examination including pelvic examination is unremarkable. A urine pregnancy test and Thyroid stimulating hormone are within normal limits. Urinalysis is normal. Which of the following is the most appropriate initial step in management?

A) Reassure that she is menopausal transition and observe

B) Obtain Serum FSH level

C) Start Oral Contraceptive Pills

D) Endometrial Biopsy

E) Oral Progestin

Question of the Week # 369

369)  A 56 year old post-menopausal woman presents to your office for evaluation of occasional vaginal spotting for past two weeks. She has not had a menstrual period for the past five years.  She  has never taken hormone replacement therapy.  She denies any fever or dysuria. She is sexually active and enjoys it. Her bleeding is unrelated to sexual activity. She has no other past medical problems and otherwise, feels healthy. Physical examination is unremarkable. A transvaginal ultrasound reveals endometrial stripe thickness of 3mm. She is reassured and sent home. Two months later she is re-evaluated in your office for persistent vaginal spotting that has not resolved. She has seen another primary care physician a week ago for a second opinion because she was concerned. He repeated a transvaginal ultrasound which showed endometrial stripe thickness unchanged at 3 mm.  Which of the following is the most appropriate management recommendation?

A) A trial of vaginal estrogen

B) Reassure and Observe

C) Vaginal pH testing

D) Oral Progestin Trial

E) Endometrial Biopsy

Question of the Week # 369

369)  A 56 year old post-menopausal woman presents to your office for evaluation of occasional vaginal spotting for past two weeks. She has not had a menstrual period for the past five years.  She  has never taken hormone replacement therapy.  She denies any fever or dysuria. She is sexually active and enjoys it. Her bleeding is unrelated to sexual activity. She has no other past medical problems and otherwise, feels healthy. Physical examination is unremarkable. A transvaginal ultrasound reveals endometrial stripe thickness of 3mm. She is reassured and sent home. Two months later she is re-evaluated in your office for persistent vaginal spotting that has not resolved. She has seen another primary care physician a week ago for a second opinion because she was concerned. He repeated a transvaginal ultrasound which showed endometrial stripe thickness unchanged at 3 mm.  Which of the following is the most appropriate management recommendation?

A) A trial of vaginal estrogen

B) Reassure and Observe

C) Vaginal pH testing

D) Oral Progestin Trial

E) Endometrial Biopsy

Question of the Week # 368

368)  A 58 year old post-menopausal woman presents to your office with intermittent vaginal bleeding for the past 1 month. She has not had a menstrual period for the past six years.  She  has never taken hormone replacement therapy. She reports burning and irritation upon sexual intercourse. She denies any fever or dysuria. She has no other past medical problems and otherwise, feels healthy. On pelvic examination, vaginal epithelium is smooth, dry and shiny with complete loss of rugae. There are no obvious masses or polyps. Vaginal pH is 6.5 . Urinalysis is normal and is negative for nitrite or leucoesterase. A transvaginal ultrasound reveals endometrial stripe thickness of 2mm. Which of the following is the most appropriate next step in management?

A) Endometrial biopsy

B) Vaginal Estrogen Cream

C) Vaginal Lubricant Cream

D) Oral Estradiol

E) Check serum estradiol levels

Question of the Week # 368

368)  A 58 year old post-menopausal woman presents to your office with intermittent vaginal bleeding for the past 1 month. She has not had a menstrual period for the past six years.  She  has never taken hormone replacement therapy. She reports burning and irritation upon sexual intercourse. She denies any fever or dysuria. She has no other past medical problems and otherwise, feels healthy. On pelvic examination, vaginal epithelium is smooth, dry and shiny with complete loss of rugae. There are no obvious masses or polyps. Vaginal pH is 6.5 . Urinalysis is normal and is negative for nitrite or leucoesterase. A transvaginal ultrasound reveals endometrial stripe thickness of 2mm. Which of the following is the most appropriate next step in management?

A) Endometrial biopsy

B) Vaginal Estrogen Cream

C) Vaginal Lubricant Cream

D) Oral Estradiol

E) Check serum estradiol levels

Question of the Week # 367

367)  A 62 year old woman presents to your office with complaints of vaginal spotting for the past three months. Occasionally, she also had vaginal bleeding. She is concerned with this new development because she has not has not had a menstrual period for the past  ten years. She  has never taken hormone replacement therapy. She also reports burning and irritation upon sexual intercourse. She denies any fever or dysuria. She has no other past medical problems and otherwise, feels healthy. On pelvic examination, vaginal epithelium is smooth, dry and shiny with complete loss of rugae. There are no obvious masses or polyps. Vaginal pH is 6.5 . Urinalysis is normal and is negative for nitrite or leucoesterase. Which of the following is the most appropriate next step in management?

A) Endometrial biopsy

B) Vaginal Estrogen Cream

C) Vaginal Lubricant Cream

D) Oral Estradiol

E) Check serum estradiol levels

Question of the Week # 367

367)  A 62 year old woman presents to your office with complaints of vaginal spotting for the past three months. Occasionally, she also had vaginal bleeding. She is concerned with this new development because she has not has not had a menstrual period for the past  ten years. She  has never taken hormone replacement therapy. She also reports burning and irritation upon sexual intercourse. She denies any fever or dysuria. She has no other past medical problems and otherwise, feels healthy. On pelvic examination, vaginal epithelium is smooth, dry and shiny with complete loss of rugae. There are no obvious masses or polyps. Vaginal pH is 6.5 . Urinalysis is normal and is negative for nitrite or leucoesterase. Which of the following is the most appropriate next step in management?

A) Endometrial biopsy

B) Vaginal Estrogen Cream

C) Vaginal Lubricant Cream

D) Oral Estradiol

E) Check serum estradiol levels

Question of the Week # 366

366)  A 59 year old woman is evaluated in your office for vaginal bleeding. The patient has not had a menstrual period for the past eight years. She  has never taken hormone replacement therapy. Over the past 6 months she has had several episodes of spotting. The bleeding is more pronounced after sexual activity. Physical examination including pelvic examination is unremarkable. Which of the following is the most common cause of post-menopausal bleeding?

A) Endometrial Carcinoma

B) Endometrial Hyperplasia

C) Cervical polyps

D) Vaginal Atrophy

E) Fibroids

Question of the Week # 366

366)  A 59 year old woman is evaluated in your office for vaginal bleeding. The patient has not had a menstrual period for the past eight years. She  has never taken hormone replacement therapy. Over the past 6 months she has had several episodes of spotting. The bleeding is more pronounced after sexual activity. Physical examination including pelvic examination is unremarkable. Which of the following is the most common cause of post-menopausal bleeding?

A) Endometrial Carcinoma

B) Endometrial Hyperplasia

C) Cervical polyps

D) Vaginal Atrophy

E) Fibroids

Question of the Week # 365

365)  A 26 year old woman presents to the outpatient gynecology clinic with complaints of for intermittent vaginal bleeding. She has started Combination oral contraceptive pills 3 months ago. Initially, she had spotting in the first month after starting OC pills however, she now has frank bleeding for past 4 weeks. Her scheduled menstrual period usually, occurs during the pill free period of the month.  She denies any dysuria , fever, vaginal discharge or post-coital bleeding. She smoked about 1 pack per day for the past eight years. She denies alcohol or drug use. Physical examination including pelvic examination is unremarkable. There is no vaginal discharge or adnexal tenderness. A urine pregnancy test is negative. Which of the following is the first step in managing this patient's intermenstrual bleeding?

A) Observation

B) Smoking Cessation

C) Pelvic ultrasound

D) Increase Estrogen component of the pill

E) Change the progesterone component to Levonorgestrel

Question of the Week # 365

365)  A 26 year old woman presents to the outpatient gynecology clinic with complaints of for intermittent vaginal bleeding. She has started Combination oral contraceptive pills 3 months ago. Initially, she had spotting in the first month after starting OC pills however, she now has frank bleeding for past 4 weeks. Her scheduled menstrual period usually, occurs during the pill free period of the month.  She denies any dysuria , fever, vaginal discharge or post-coital bleeding. She smoked about 1 pack per day for the past eight years. She denies alcohol or drug use. Physical examination including pelvic examination is unremarkable. There is no vaginal discharge or adnexal tenderness. A urine pregnancy test is negative. Which of the following is the first step in managing this patient's intermenstrual bleeding?

A) Observation

B) Smoking Cessation

C) Pelvic ultrasound

D) Increase Estrogen component of the pill

E) Change the progesterone component to Levonorgestrel

Question of the Week # 364

364)  A 28 year old woman seeks your advice regarding an effective contraception method. She is sexually active with her long term boy-friend. He has been using condoms however, he prefers not to use them on a regular basis . She tells you that she does not want to consider an Intra-Uterine Device Her past medical history is significant for Gastro-esophageal reflux disease and well- controlled Epilepsy. Her medications include omeprazole and carbamazepine.  She does not smoke. On examination, she is age appropriate with normal vitals. Physical examination including pelvic examination is normal. Which of the following contraceptive methods is most appropriate for this patient?

A) Continuous Combination Oral Contraceptive Pills

B) Cyclical Combination Oral Contraceptive Pills

C) Diaphragm with Spermicides

D) Estrogen-Progesterone vaginal ring ( Nuva-Ring)

E) Depot Medroxy Progesterone

Question of the Week # 364

364)  A 28 year old woman seeks your advice regarding an effective contraception method. She is sexually active with her long term boy-friend. He has been using condoms however, he prefers not to use them on a regular basis . She tells you that she does not want to consider an Intra-Uterine Device Her past medical history is significant for Gastro-esophageal reflux disease and well- controlled Epilepsy. Her medications include omeprazole and carbamazepine.  She does not smoke. On examination, she is age appropriate with normal vitals. Physical examination including pelvic examination is normal. Which of the following contraceptive methods is most appropriate for this patient?

A) Continuous Combination Oral Contraceptive Pills

B) Cyclical Combination Oral Contraceptive Pills

C) Diaphragm with Spermicides

D) Estrogen-Progesterone vaginal ring ( Nuva-Ring)

E) Depot Medroxy Progesterone

Question of the Week # 363

363)  A 25 year old woman presents to your office with complaints of inter-menstrual vaginal bleeding  for the past one month. She is sexually active. She never used barrier methods for contraception but she has been on cyclical combination oral contraceptive pills ( Ethinyl estradiol + Levonorgestrol) for the past 3 months. She denies any fever or vaginal discharge or dysuria or pain. Her menstrual periods occur as scheduled every month during the pill free period however, she also has been experiencing inter-menstrual bleeding only for the past one month and sometimes, more after sexual activity. She never had irregular bleeding in the past and her scheduled periods have always been regular and on time. She denies smoking , alcohol or drug use. Upon physical examination, she is afebrile. There is no obvious vaginal discharge. When gentle endocervical swabbing is attempted, bleeding from endocervix is noted. On bimanual examination, she has no adnexal tenderness. A urine pregnancy test is negative. Which of the following is the most appropriate first management option?

A) Reassure that this is OC Pill related bleeding and will abate.

B) Test for N. gonorrhoeae and C. trachomatis

C) Increase the dose of Ethinyl Estradiol

D) Empiric antibiotic therapy for Gonorrhea and Chlamydia

E) Discontinue OC pills

Question of the Week # 363

363)  A 25 year old woman presents to your office with complaints of inter-menstrual vaginal bleeding  for the past one month. She is sexually active. She never used barrier methods for contraception but she has been on cyclical combination oral contraceptive pills ( Ethinyl estradiol + Levonorgestrol) for the past 3 months. She denies any fever or vaginal discharge or dysuria or pain. Her menstrual periods occur as scheduled every month during the pill free period however, she also has been experiencing inter-menstrual bleeding only for the past one month and sometimes, more after sexual activity. She never had irregular bleeding in the past and her scheduled periods have always been regular and on time. She denies smoking , alcohol or drug use. Upon physical examination, she is afebrile. There is no obvious vaginal discharge. When gentle endocervical swabbing is attempted, bleeding from endocervix is noted. On bimanual examination, she has no adnexal tenderness. A urine pregnancy test is negative. Which of the following is the most appropriate first management option?

A) Reassure that this is OC Pill related bleeding and will abate.

B) Test for N. gonorrhoeae and C. trachomatis

C) Increase the dose of Ethinyl Estradiol

D) Empiric antibiotic therapy for Gonorrhea and Chlamydia

E) Discontinue OC pills

Question of the Week # 362

362)  A 26 year old woman presents to your office with complaints of intermittent vaginal bleeding  after she started using oral contraceptive pills 1 month ago. She uses continuous oral contraceptive pill combination of ethinyl estradiol and norethindrone. She reports her bleeding is troublesome and interferes with activity. Because of the bleeding, she is considering discontinuing the oral pills but her partner does not want to use barrier methods of contraception. She is distressed and seeks some remedy to address this issue. She never had irregular bleeding in the past and her scheduled periods have always been regular and on time. Her bleeding is unrelated to sexual activity and is not associated with pain. She denies any dysuria, fever or vaginal discharge. She denies smoking or alcohol use. Physical examination including pelvic examination is unremarkable. There is no vaginal discharge or adnexal tenderness. A urine pregnancy test is negative and serum thyroid stimulating hormone as well as prolactin level are within normal limits. Which of the following is the most appropriate management option?

A) Observation

B) Stop the pills for 3 days and then resume at least 21 days

C) Pelvic ultrasound

D) Discontinue Oral Contraceptive pills

E) Vaginal fluid Nucleic Acid Test for Chlamydia Trachomatis

Question of the Week # 362

362)  A 26 year old woman presents to your office with complaints of intermittent vaginal bleeding  after she started using oral contraceptive pills 1 month ago. She uses continuous oral contraceptive pill combination of ethinyl estradiol and norethindrone. She reports her bleeding is troublesome and interferes with activity. Because of the bleeding, she is considering discontinuing the oral pills but her partner does not want to use barrier methods of contraception. She is distressed and seeks some remedy to address this issue. She never had irregular bleeding in the past and her scheduled periods have always been regular and on time. Her bleeding is unrelated to sexual activity and is not associated with pain. She denies any dysuria, fever or vaginal discharge. She denies smoking or alcohol use. Physical examination including pelvic examination is unremarkable. There is no vaginal discharge or adnexal tenderness. A urine pregnancy test is negative and serum thyroid stimulating hormone as well as prolactin level are within normal limits. Which of the following is the most appropriate management option?

A) Observation

B) Stop the pills for 3 days and then resume at least 21 days

C) Pelvic ultrasound

D) Discontinue Oral Contraceptive pills

E) Vaginal fluid Nucleic Acid Test for Chlamydia Trachomatis

Question of the Week # 361

361)  A 22 year old woman is seen in the outpatient clinic for intermittent vaginal bleeding. For the past two months, she has had spotting and occasionally, frank bleeding  even before her scheduled menstrual period. It is unrelated to sexual activity and is not associated with pain. She denies any dysuria or fever.  She is sexually active with her fiancee and she reports taking cyclical combined oral contraceptive pills ( OC pills) for the past 2 months. She has been following the exact directions regarding the use of oral contraceptive pills and her scheduled period occurs during the contraceptive free interval however, this unscheduled spotting and bleeding is bothering her. She denies smoking or alcohol use. Physical examination including pelvic examination is unremarkable. There is no vaginal discharge or adnexal tenderness. A urine pregnancy test is negative and serum thyroid stimulating hormone as well as prolactin level are within normal limits. Which of the following is the most appropriate management option?

A) Pelvic ultrasound

B) Reassure and counsel on consistent OC pill use

C) Increase estrogen component of the pills

D) Switch to continuous combined OC pill regimen

E) Discontinue Oral Contraceptive pills

Question of the Week # 361

361)  A 22 year old woman is seen in the outpatient clinic for intermittent vaginal bleeding. For the past two months, she has had spotting and occasionally, frank bleeding  even before her scheduled menstrual period. It is unrelated to sexual activity and is not associated with pain. She denies any dysuria or fever.  She is sexually active with her fiancee and she reports taking cyclical combined oral contraceptive pills ( OC pills) for the past 2 months. She has been following the exact directions regarding the use of oral contraceptive pills and her scheduled period occurs during the contraceptive free interval however, this unscheduled spotting and bleeding is bothering her. She denies smoking or alcohol use. Physical examination including pelvic examination is unremarkable. There is no vaginal discharge or adnexal tenderness. A urine pregnancy test is negative and serum thyroid stimulating hormone as well as prolactin level are within normal limits. Which of the following is the most appropriate management option?

A) Pelvic ultrasound

B) Reassure and counsel on consistent OC pill use

C) Increase estrogen component of the pills

D) Switch to continuous combined OC pill regimen

E) Discontinue Oral Contraceptive pills

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Question of the Week # 360

360)  A 30 year old woman presents to your office accompanied by her husband. She is concerned about her inability to conceive despite having regular intercourse for the past six months.  Her menstrual cycles have always been regular and she has not been using oral contraceptives for the past 10 months. She denies any cold or heat intolerance. She has no other complaints. She does not smoke or drink alcohol. On examination, she is age-appropriate. Pelvic examination is benign. A urine pregnancy test is negative. You counsel the couple and  advise them on continuing regular sexual intercourse. Which of the following is the most appropriate next step?

A) Semen analysis

B) Re-evaluate in 6 months

C) Obtain luteal-phase progesterone level

D) Serum FSH level

E) Hysterosalpingography

Question of the Week # 360

360)  A 30 year old woman presents to your office accompanied by her husband. She is concerned about her inability to conceive despite having regular intercourse for the past six months.  Her menstrual cycles have always been regular and she has not been using oral contraceptives for the past 10 months. She denies any cold or heat intolerance. She has no other complaints. She does not smoke or drink alcohol. On examination, she is age-appropriate. Pelvic examination is benign. A urine pregnancy test is negative. You counsel the couple and  advise them on continuing regular sexual intercourse. Which of the following is the most appropriate next step?

A) Semen analysis

B) Re-evaluate in 6 months

C) Obtain luteal-phase progesterone level

D) Serum FSH level

E) Hysterosalpingography

Question of the Week # 359

359)  A 50 year old woman with history of Diabetes Mellitus presents to your office with complaining of discomfort in her both legs for past few months. She describes unpleasant sensations as well as abnormal sensations such as including tingling, creeping and itching sensations deep in her legs while sitting. Walking a few steps relieves her symptoms. She denies any pain in the legs upon walking or at rest. Physical examination reveals slightly diminished pulses in bilateral lower extremities.  Which of the following is the first step in managing her symptoms?

A) Nerve Conduction Studies

B) Cilostozol

C) Dopamine Agonists

D) Obtain Serum ferritin

E) Gabapentin

Question of the Week # 359

359)  A 50 year old woman with history of Diabetes Mellitus presents to your office with complaining of discomfort in her both legs for past few months. She describes unpleasant sensations as well as abnormal sensations such as including tingling, creeping and itching sensations deep in her legs while sitting. Walking a few steps relieves her symptoms. She denies any pain in the legs upon walking or at rest. Physical examination reveals slightly diminished pulses in bilateral lower extremities.  Which of the following is the first step in managing her symptoms?

A) Nerve Conduction Studies

B) Cilostozol

C) Dopamine Agonists

D) Obtain Serum ferritin

E) Gabapentin

Question of the Week # 358

358)  A 36 year old man presents to your office for an annual health examination. During review of systems, he reports  feeling excessively sleepy during the day and forgetful at work. He states no matter how much he slept, it  does not make him feel rested in the morning. He denies snoring at night. He is athletic and maintains his body weight in a healthy range. He denies alcohol consumption, smoking or excessive caffeine use. His girlfriend reports that he abruptly moves his legs often during the night and that disturbs her as well. She has noticed him flexing his leg and extending his great toe repeatedly. The patient is not aware of this and he denies any pain or discomfort in his legs. Physical examination is unremarkable. Laboratory investigations including complete blood count, serum creatinine, electrolytes and a thyroid stimulating hormone are within normal limits. Which of the following is the most likely diagnosis?

A) Complex Partial Seizures

B) Restless leg syndrome

C) Nocturnal Leg Cramps

D) Myoclonus

E) Periodic Limb Movement Disorder

F) Sleep Apnea

Question of the Week # 358

358)  A 36 year old man presents to your office for an annual health examination. During review of systems, he reports  feeling excessively sleepy during the day and forgetful at work. He states no matter how much he slept, it  does not make him feel rested in the morning. He denies snoring at night. He is athletic and maintains his body weight in a healthy range. He denies alcohol consumption, smoking or excessive caffeine use. His girlfriend reports that he abruptly moves his legs often during the night and that disturbs her as well. She has noticed him flexing his leg and extending his great toe repeatedly. The patient is not aware of this and he denies any pain or discomfort in his legs. Physical examination is unremarkable. Laboratory investigations including complete blood count, serum creatinine, electrolytes and a thyroid stimulating hormone are within normal limits. Which of the following is the most likely diagnosis?

A) Complex Partial Seizures

B) Restless leg syndrome

C) Nocturnal Leg Cramps

D) Myoclonus

E) Periodic Limb Movement Disorder

F) Sleep Apnea

Question of the Week # 357

357)  A 52 year old man is seen in your office for pain in his legs that bothers him during sleep. He describes these episodes as aching and painful tightness particularly, in his posterior calves. The pain is relieved by forcefully stretching his leg muscles in opposite direction. He experiences these at least for about 2 to 3 nights per week and interferes with his sleep. He works as a coach for the local high-school soccer team and is physically very active. He has no other past medical problems and enjoys healthy living. On examination, his blood pressure is 122/80. Oral mucosa re moist.  There are no focal neuroligical deficits. Extremities appear normal with out any deformity, swelling or palpable tenderness. Peripheral pulses are normal. Serum electrolytes, Calcium, magnesium , a complete blood count, thyroid stimulating hormone and blood glucose are all within normal limits.  Which of the following is the most appropriate next step in managing his problem?

A) Start Ropinirole

B) Start Bromocriptine

C) Recommend non-pharmacological measures

D) Quinine Trial

E) Oral Iron Trial

Question of the Week # 357

357)  A 52 year old man is seen in your office for pain in his legs that bothers him during sleep. He describes these episodes as aching and painful tightness particularly, in his posterior calves. The pain is relieved by forcefully stretching his leg muscles in opposite direction. He experiences these at least for about 2 to 3 nights per week and interferes with his sleep. He works as a coach for the local high-school soccer team and is physically very active. He has no other past medical problems and enjoys healthy living. On examination, his blood pressure is 122/80. Oral mucosa re moist.  There are no focal neuroligical deficits. Extremities appear normal with out any deformity, swelling or palpable tenderness. Peripheral pulses are normal. Serum electrolytes, Calcium, magnesium , a complete blood count, thyroid stimulating hormone and blood glucose are all within normal limits.  Which of the following is the most appropriate next step in managing his problem?

A) Start Ropinirole

B) Start Bromocriptine

C) Recommend non-pharmacological measures

D) Quinine Trial

E) Oral Iron Trial

Question of the Week # 356

356) A 7 year old boy is evaluated in your office for frequent episodes of “staring spells” while at school. His teacher reports that he does not seem to concentrate during the class and stares blankly in to space. He has had many such episodes in the past six months that got his teacher very concerned. Waving a hand in front of his eyes and calling out his name does not seem to disrupt these episodes. Often he returns to his norm when the boy next to him physically moves him or tickles him. He is otherwise, healthy and plays well with other kids without any issues. His mother also has noticed such episodes while he was watching television at home. On examination, he appears comfortable and healthy. There are no physical abnormalities.  He is attentive to your questions and does not seem to be distracted. Which of the following is the most appropriate next step?

A) Re-assurance

B) Obtain Electro-Encephalogram

C) Refer to Child Psychiatry

D) Start Methylphenidate trial

E) Refer to Neurology

Question of the Week # 356

356) A 7 year old boy is evaluated in your office for frequent episodes of “staring spells” while at school. His teacher reports that he does not seem to concentrate during the class and stares blankly in to space. He has had many such episodes in the past six months that got his teacher very concerned. Waving a hand in front of his eyes and calling out his name does not seem to disrupt these episodes. Often he returns to his norm when the boy next to him physically moves him or tickles him. He is otherwise, healthy and plays well with other kids without any issues. His mother also has noticed such episodes while he was watching television at home. On examination, he appears comfortable and healthy. There are no physical abnormalities.  He is attentive to your questions and does not seem to be distracted. Which of the following is the most appropriate next step?

A) Re-assurance

B) Obtain Electro-Encephalogram

C) Refer to Child Psychiatry

D) Start Methylphenidate trial

E) Refer to Neurology

Question of the Week # 355

355)  A 6 year old boy is brought to your office with history of staring spells. He has had three such episodes in the past one month. His mother reports that during the episode he states blankly in to space for about two to three minutes. He does not respond to verbal commands during such episodes. The episodes are usually, followed by a period during which he is either confused or drowsy for about 30 minutes. On two such occasions, he reported unpleasant taste sensation prior to the staring spells. On examination, he appears comfortable and healthy. There are no physical abnormalities. Basic laboratory investigations including thyroid stimulating hormone are normal. Which of the following is the most appropriate diagnosis?

A) Attention Deficit Hyperactivity Disorder

B) Absence Seizures

C) Complex Partial Seizures

D) Simple Partial Seizures

E) Generalized Seizures

Question of the Week # 355

355)  A 6 year old boy is brought to your office with history of staring spells. He has had three such episodes in the past one month. His mother reports that during the episode he states blankly in to space for about two to three minutes. He does not respond to verbal commands during such episodes. The episodes are usually, followed by a period during which he is either confused or drowsy for about 30 minutes. On two such occasions, he reported unpleasant taste sensation prior to the staring spells. On examination, he appears comfortable and healthy. There are no physical abnormalities. Basic laboratory investigations including thyroid stimulating hormone are normal. Which of the following is the most appropriate diagnosis?

A) Attention Deficit Hyperactivity Disorder

B) Absence Seizures

C) Complex Partial Seizures

D) Simple Partial Seizures

E) Generalized Seizures

Question of the Week # 354

354)  A 74 year old woman is being treated in the hospital for community acquired pneumonia. She has been receiving ceftriaxone and azithromycin. On second day after admission she is found by the nurse to be staring in to the space and shaking her left extremity. When you walk in to the room,  she recognizes you and reports that she is unable to control movements in her left extremity. On examination, she is afebrile and vitals are stable. A rhythmic movement of her left upper extremity is noted. She is conscious  and is repeatedly grinding her teeth. An electroencephalogram has been ordered. Based on the clinical information, which of the following is the most likely diagnosis?

A)  Complex Partial Seizures

B) Generalized Tonic-Clonic Seizures

C) Absence Seizures

D) Aura

E) Drug induced myoclonus

Question of the Week # 354

354)  A 74 year old woman is being treated in the hospital for community acquired pneumonia. She has been receiving ceftriaxone and azithromycin. On second day after admission she is found by the nurse to be staring in to the space and shaking her left extremity. When you walk in to the room,  she recognizes you and reports that she is unable to control movements in her left extremity. On examination, she is afebrile and vitals are stable. A rhythmic movement of her left upper extremity is noted. She is conscious  and is repeatedly grinding her teeth. An electroencephalogram has been ordered. Based on the clinical information, which of the following is the most likely diagnosis?

A)  Complex Partial Seizures

B) Generalized Tonic-Clonic Seizures

C) Absence Seizures

D) Aura

E) Drug induced myoclonus

Question of the Week # 353

353)  A 54 year old woman is found by her husband wandering and trying to undress herself two miles away from her home . Her husband tried to question her, however, she did not recognize him, did not respond to his questions and when he tried to restrain her, she became physically aggressive. Upon presentation in the Emergency Department, she appears confused and does not recall the event. There is no history of drug abuse or alcoholism. There is no history of any significant past medical problems. Examination shows normal vitals. There are no focal neurological deficits. She is confused and not oriented to place and person. Which of the following is the most likely diagnosis?

A)  Temporal Lobe Epilepsy

B) Depersonalization Disorder

C) Domestic abuse

D) Dissociative Fugue

E) Manic Episode

Question of the Week # 353

353)  A 54 year old woman is found by her husband wandering and trying to undress herself two miles away from her home . Her husband tried to question her, however, she did not recognize him, did not respond to his questions and when he tried to restrain her, she became physically aggressive. Upon presentation in the Emergency Department, she appears confused and does not recall the event. There is no history of drug abuse or alcoholism. There is no history of any significant past medical problems. Examination shows normal vitals. There are no focal neurological deficits. She is confused and not oriented to place and person. Which of the following is the most likely diagnosis?

A)  Temporal Lobe Epilepsy

B) Depersonalization Disorder

C) Domestic abuse

D) Dissociative Fugue

E) Manic Episode

Question of the Week # 352

352)  A 26 year old man is brought by the Emergency Medical Services because he was found on the streets of Miami and as per by-standers, was unable to recall where he came from. Upon questioning in the Emeregency Room, he denies any drug abuse or alcoholism. He reports that his name is John and he worked as a plumber. He does not remember if he had a family or what work he did.  He says he can not remember how he got to Miami and where he traveled from. A flight ticket receipt from Las-Vegas to Miami is found in his coat pocket. He has an identity card in his wallet that states his name as Steven and that he serves as a Cop in Los Angeles Police Department. He appears comfortable.  Examination shows normal vitals. There are no focal neurological deficits. An official from Los Angeles police department reports that Steven had always been a great colleague, did not have any problems in the past and he was surprised that he suddenly did not show up at work for the past two days. Which of the following is the most likely diagnosis?

A) Post Traumatic Stress Disorder

B) Dissociative Identity disorder

C) Dissociative amnesia

D) Depersonalization

E) Dissociative Fugue

Question of the Week # 352

352)  A 26 year old man is brought by the Emergency Medical Services because he was found on the streets of Miami and as per by-standers, was unable to recall where he came from. Upon questioning in the Emeregency Room, he denies any drug abuse or alcoholism. He reports that his name is John and he worked as a plumber. He does not remember if he had a family or what work he did.  He says he can not remember how he got to Miami and where he traveled from. A flight ticket receipt from Las-Vegas to Miami is found in his coat pocket. He has an identity card in his wallet that states his name as Steven and that he serves as a Cop in Los Angeles Police Department. He appears comfortable.  Examination shows normal vitals. There are no focal neurological deficits. An official from Los Angeles police department reports that Steven had always been a great colleague, did not have any problems in the past and he was surprised that he suddenly did not show up at work for the past two days. Which of the following is the most likely diagnosis?

A) Post Traumatic Stress Disorder

B) Dissociative Identity disorder

C) Dissociative amnesia

D) Depersonalization

E) Dissociative Fugue

Question of the Week # 351

351)  A 22 year old woman presents to the emergency room with complaints of shortness of breath, dizziness and tingling in her extremities. Her past medical history is unremarkable.  She denies any history of blood clots in her family.  She denies any recent long flight trips. She does not smoke. On examination, pulse is 110/min and  respiratory rate is 26/min. She is afebrile and blood pressure is within normal limits.  Pulse oximetry reveals 99% on room air. There are no physical abnormalities . A D-dimer level is 50µg/l . An electrocardiogram shows sinus tachycardia without ant ST-T changes. Chest x-ray is unremarkable. Which of the following is the most appropriate next step in management?

A) Start Conazepam

B) Re-breathing in to a paper bag

C) Start Calcium Gluconate

D) Re-assure and teach to deliberately slow down respiration

E) Admit to ward and start high flow oxygen

Question of the Week # 351

351)  A 22 year old woman presents to the emergency room with complaints of shortness of breath, dizziness and tingling in her extremities. Her past medical history is unremarkable.  She denies any history of blood clots in her family.  She denies any recent long flight trips. She does not smoke. On examination, pulse is 110/min and  respiratory rate is 26/min. She is afebrile and blood pressure is within normal limits.  Pulse oximetry reveals 99% on room air. There are no physical abnormalities . A D-dimer level is 50µg/l . An electrocardiogram shows sinus tachycardia without ant ST-T changes. Chest x-ray is unremarkable. Which of the following is the most appropriate next step in management?

A) Start Conazepam

B) Re-breathing in to a paper bag

C) Start Calcium Gluconate

D) Re-assure and teach to deliberately slow down respiration

E) Admit to ward and start high flow oxygen

Question of the Week # 350

350)  A 68 year old man with recently diagnosed Parkinson's disease is evaluated during a follow-up visit. He was started on medications to help with the motor symptoms of his disease. He reports that the medications have not helped him much however, he has been experiencing difficulty concentrating on his job and has lost interest in life. He reports inability to relish his life, sadness and decreased appetite. On examination, his mood is depressed . His facial expressions are masked. He has a resting tremor and generalized slowness of movements.  Which of the following is the most appropriate next step in management?

A) Discontinue Anti-parkinson's medications

B) Increase the dose of anti-parkinson's medications

C) Inquire about Suicidal ideation

D) Refer to Neurology

E) Admit to Psychiatry ward

Question of the Week # 350

350)  A 68 year old man with recently diagnosed Parkinson's disease is evaluated during a follow-up visit. He was started on medications to help with the motor symptoms of his disease. He reports that the medications have not helped him much however, he has been experiencing difficulty concentrating on his job and has lost interest in life. He reports inability to relish his life, sadness and decreased appetite. On examination, his mood is depressed . His facial expressions are masked. He has a resting tremor and generalized slowness of movements.  Which of the following is the most appropriate next step in management?

A) Discontinue Anti-parkinson's medications

B) Increase the dose of anti-parkinson's medications

C) Inquire about Suicidal ideation

D) Refer to Neurology

E) Admit to Psychiatry ward

Question of the Week # 349

349)  A 46 year old man presents to your office with generalized itching. The itching is severe during shower and for past few weeks, it has become intolerable. He denies any headache, chest pain or shortness of breath.  He does not smoke and consumes alcohol only occasionally. He works as a public health officer in New York City. He reports no sleep related problems, denies snoring at night or day-time drowsiness. He denies any past medical problems . On examination, he is overweight, afebrile,  Blood pressure 110/60 mm Hg,  Heart Rate 88/min, Respiratory rate is 16/minute. Physical examination is benign. There is no splenomegaly. A CT Scan of the chest, abdomen and pelvis does not reveal any neoplasm. Laboratory investigations reveal :

WBC : 9.0k/µl

Hemoglobin 20gm% ( N = 13.5 to 16.5gm%

Hematocrit 62%

Mean Corpuscular Volume ( MCV) 65µl

Platelet count 280k/µl

Serum Creatinine 0.8mg%

Serum Calcium 9.8mg%

Erythropoetin Level 3U/L ( Normal 5 to 25U/L)

Which of the following is features can be seen with this condition?

A) Low serum uric acid

B) Iron deficiency

C) Elevated HGBA2 fraction on HGB electrophoresis

D) Reduced Leucocyte Alkaline Phosphatase

E) Elevated Reticulocyte Count

Question of the Week # 349

349)  A 46 year old man presents to your office with generalized itching. The itching is severe during shower and for past few weeks, it has become intolerable. He denies any headache, chest pain or shortness of breath.  He does not smoke and consumes alcohol only occasionally. He works as a public health officer in New York City. He reports no sleep related problems, denies snoring at night or day-time drowsiness. He denies any past medical problems . On examination, he is overweight, afebrile,  Blood pressure 110/60 mm Hg,  Heart Rate 88/min, Respiratory rate is 16/minute. Physical examination is benign. There is no splenomegaly. A CT Scan of the chest, abdomen and pelvis does not reveal any neoplasm. Laboratory investigations reveal :

WBC : 9.0k/µl

Hemoglobin 20gm% ( N = 13.5 to 16.5gm%

Hematocrit 62%

Mean Corpuscular Volume ( MCV) 65µl

Platelet count 280k/µl

Serum Creatinine 0.8mg%

Serum Calcium 9.8mg%

Erythropoetin Level 3U/L ( Normal 5 to 25U/L)

Which of the following is features can be seen with this condition?

A) Low serum uric acid

B) Iron deficiency

C) Elevated HGBA2 fraction on HGB electrophoresis

D) Reduced Leucocyte Alkaline Phosphatase

E) Elevated Reticulocyte Count

Question of the Week # 348

348)  A 6 year old boy is evaluated in your office for complaints of generalized swelling of his body. His mother reports she has noticed increasing swelling of his face, abdomen and extremities over the past 3 weeks.  He does not have any significant past medical problems  There is no history of fever or sore-throat. He denies shortness of breath or cough. On examination,  he is afebrile,  Blood pressure 100/60 mm Hg,  Heart Rate 88/min, Respiratory rate is 16/minute. He appears comfortable. His face is grossly swollen. There is mild ascites. Lower extremities reveal gross edema up until the level of knees.  Urinalysis showed 3+ proteinuria, no red cell or casts. A 24 hour Urine total protein is obtained and it shows proteinuria at  7.0 gm/24 hours. Serum total protein 4.0gm% and albumin 2.0gm% .  He is advised to start sodium restricted diet. Which of the following management options is most appropriate next step for this patient?

A) Admit and start Albumin infusion

B) Corticosteroid Trial

C) Renal Biopsy

D) Obtain Anti-Streptolysin O titer

E) Furosemide

Question of the Week # 348

348)  A 6 year old boy is evaluated in your office for complaints of generalized swelling of his body. His mother reports she has noticed increasing swelling of his face, abdomen and extremities over the past 3 weeks.  He does not have any significant past medical problems  There is no history of fever or sore-throat. He denies shortness of breath or cough. On examination,  he is afebrile,  Blood pressure 100/60 mm Hg,  Heart Rate 88/min, Respiratory rate is 16/minute. He appears comfortable. His face is grossly swollen. There is mild ascites. Lower extremities reveal gross edema up until the level of knees.  Urinalysis showed 3+ proteinuria, no red cell or casts. A 24 hour Urine total protein is obtained and it shows proteinuria at  7.0 gm/24 hours. Serum total protein 4.0gm% and albumin 2.0gm% .  He is advised to start sodium restricted diet. Which of the following management options is most appropriate next step for this patient?

A) Admit and start Albumin infusion

B) Corticosteroid Trial

C) Renal Biopsy

D) Obtain Anti-Streptolysin O titer

E) Furosemide

Question of the Week # 347

347)  A 34 year old man is recently diagnosed with Stage IIA Hodgkin's  lymphoma and has received one cycle of chemotherapy with Adriamycin, Bleomycin, Vinblastine and Dacarbazine. He is scheduled to receive three more cycle followed by involved field radiation therapy.  One week after his first cycle of chemotherapy, he presents to your office with increasing swelling of his legs. He denies any fever, chest pain, rash or shortness of breath. On examination, breath sounds are decreased in bilateral lower lungs. There is 2+ edema in his lower extremities. Laboratory investigations show reduced albumin at 2.5gm%. Urinalysis reveals 3+ proteinuria with out any evidence o red cells or red cell casts. A MUGA ( Multigated Acquisition Scan) has been ordered to evaluate his cardiac function and results are pending. Which of the following is most likely explanation of his presentation?

A) Adriamycin Cardiomyopathy

B)  Allergic interstitial nephritis

C) Focal Segmental Glomerulosclerosis

D) Bleomycin nephrotoxicity

E) Minimal Change Disease

Question of the Week # 347

347)  A 34 year old man is recently diagnosed with Stage IIA Hodgkin's  lymphoma and has received one cycle of chemotherapy with Adriamycin, Bleomycin, Vinblastine and Dacarbazine. He is scheduled to receive three more cycle followed by involved field radiation therapy.  One week after his first cycle of chemotherapy, he presents to your office with increasing swelling of his legs. He denies any fever, chest pain, rash or shortness of breath. On examination, breath sounds are decreased in bilateral lower lungs. There is 2+ edema in his lower extremities. Laboratory investigations show reduced albumin at 2.5gm%. Urinalysis reveals 3+ proteinuria with out any evidence o red cells or red cell casts. A MUGA ( Multigated Acquisition Scan) has been ordered to evaluate his cardiac function and results are pending. Which of the following is most likely explanation of his presentation?

A) Adriamycin Cardiomyopathy

B)  Allergic interstitial nephritis

C) Focal Segmental Glomerulosclerosis

D) Bleomycin nephrotoxicity

E) Minimal Change Disease

Question of the Week # 346

346)  A 54 year old woman presents to your office with progressively increasing swelling of her bilateral lower extremities and abdominal distension.  She denies any fever, cough or shortness of breath. Her medical history is significant for hypertension and osteoarthritis. She takes Enalapril and Hydroclorthiazide for her hypertension and Ibuprofen for osteoarthritis on a daily basis . She denies any rash. On examination,  she is afebrile,  Blood pressure 130/80 mm Hg and respiratory rate is 18/min . Auscultation reveals reduced breath sounds on both sides. Abdominal exam is remarkable for shifting dullness  consistent with ascites.  Lower extremities reveal gross edema up until the level of knees.  Urinalysis shows no eosinophils or redcells or casts,  3+ proteinuria, no nitrite or leukoesterase. Urine total protein is 6.0 gm/24 hours. Serum total protein 4.0gm% , albumin 2.0gm%. SGOT, SGPT and Alkaline phosphatase are within normal limits. Serum creatinine is o.8mg%.   Skin examination si normal with out any rash. Which of the following management options is most appropriate next step for this patient?

A) Discontinue Enalapril

B) Renal Biopsy

C) Discontinue Ibuprofen

D) Furosemide

E) Obtain Anti-Nuclear Antibodies

F) Trial of Corticosteroids

Question of the Week # 346

346)  A 54 year old woman presents to your office with progressively increasing swelling of her bilateral lower extremities and abdominal distension.  She denies any fever, cough or shortness of breath. Her medical history is significant for hypertension and osteoarthritis. She takes Enalapril and Hydroclorthiazide for her hypertension and Ibuprofen for osteoarthritis on a daily basis . She denies any rash. On examination,  she is afebrile,  Blood pressure 130/80 mm Hg and respiratory rate is 18/min . Auscultation reveals reduced breath sounds on both sides. Abdominal exam is remarkable for shifting dullness  consistent with ascites.  Lower extremities reveal gross edema up until the level of knees.  Urinalysis shows no eosinophils or redcells or casts,  3+ proteinuria, no nitrite or leukoesterase. Urine total protein is 6.0 gm/24 hours. Serum total protein 4.0gm% , albumin 2.0gm%. SGOT, SGPT and Alkaline phosphatase are within normal limits. Serum creatinine is o.8mg%.   Skin examination si normal with out any rash. Which of the following management options is most appropriate next step for this patient?

A) Discontinue Enalapril

B) Renal Biopsy

C) Discontinue Ibuprofen

D) Furosemide

E) Obtain Anti-Nuclear Antibodies

F) Trial of Corticosteroids

Question of the Week # 345

345)  A 8 year old boy is brought to the Emergency room by his mother with complaints of  shortness of breath. His mother reports she has noticed increasing swelling of his face, abdomen and extremities over the past 4 weeks. She scheduled an appointment with his pediatrician in the upcoming week however, she brought him to the ER today because he started getting distressed because of breathing difficult. The patient does not have any significant medical problems and mother reports he has always been a "good kid" at the school.  There is no history of fever or sore-throat. On examination,  he is afebrile,  Blood pressure 100/60 mm Hg (Standing) , 108/60 ( Lying Down) and Heart Rate 92/min ( Standing), 88/min (Lying Down). He is tachypneic with respiratory rate is 26/min and is using accessory muscles. His face is grossly swollen. Breath sounds are reduced on both sides and there is massive ascites with scrotal edema. Lower extremities reveal gross edema up until the level of knees.  Urinalysis showed 3+ proteinuria, no red cell casts or hematuria. Urine total protein is 8.0 gm/24 hours. Serum total protein 4.0gm% and albumin 2.0gm% .  A chest X-ray shows bilateral pleural effusions. Which of the following management options is most appropriate next step for this patient?

A) Renal Biopsy

B) Corticosteroid Trial

C) Furosemide

D) Furosemide with Albumin infusion

E) Consult Nephrology

Question of the Week # 345

345)  A 8 year old boy is brought to the Emergency room by his mother with complaints of  shortness of breath. His mother reports she has noticed increasing swelling of his face, abdomen and extremities over the past 4 weeks. She scheduled an appointment with his pediatrician in the upcoming week however, she brought him to the ER today because he started getting distressed because of breathing difficult. The patient does not have any significant medical problems and mother reports he has always been a "good kid" at the school.  There is no history of fever or sore-throat. On examination,  he is afebrile,  Blood pressure 100/60 mm Hg (Standing) , 108/60 ( Lying Down) and Heart Rate 92/min ( Standing), 88/min (Lying Down). He is tachypneic with respiratory rate is 26/min and is using accessory muscles. His face is grossly swollen. Breath sounds are reduced on both sides and there is massive ascites with scrotal edema. Lower extremities reveal gross edema up until the level of knees.  Urinalysis showed 3+ proteinuria, no red cell casts or hematuria. Urine total protein is 8.0 gm/24 hours. Serum total protein 4.0gm% and albumin 2.0gm% .  A chest X-ray shows bilateral pleural effusions. Which of the following management options is most appropriate next step for this patient?

A) Renal Biopsy

B) Corticosteroid Trial

C) Furosemide

D) Furosemide with Albumin infusion

E) Consult Nephrology

Question of the Week # 344

344) A 65 year old man with history of smoking is recently diagnosed with Stage IA non-small cell lung cancer of the right lung. He has no other significant past medical history. He was subsequently admitted and underwent wedge lower left pulmonary resection via. Video-assisted thoracic surgery (VATS). On the 2^nd postoperative day, a chest x-ray reveals right sided pleural effusion was detected on chest X-Ray. On examination, he is afebrile.  Breath sounds are decreased on the right side and there is dullness to auscultation. A thoracentesis is performed and a chest tube is inserted. Which of the following is most likely to be found on this pleural fluid analysis?

A) Low glucose

B) Elevated LDH > 1000 IU/L

C) High Amylase

D) Cholesterol level > 200mg%

E) Triglycerides > 110mg%

Question of the Week # 344

344) A 65 year old man with history of smoking is recently diagnosed with Stage IA non-small cell lung cancer of the right lung. He has no other significant past medical history. He was subsequently admitted and underwent wedge lower left pulmonary resection via. Video-assisted thoracic surgery (VATS). On the 2^nd postoperative day, a chest x-ray reveals right sided pleural effusion was detected on chest X-Ray. On examination, he is afebrile.  Breath sounds are decreased on the right side and there is dullness to auscultation. A thoracentesis is performed and a chest tube is inserted. Which of the following is most likely to be found on this pleural fluid analysis?

A) Low glucose

B) Elevated LDH > 1000 IU/L

C) High Amylase

D) Cholesterol level > 200mg%

E) Triglycerides > 110mg%

Question of the Week # 343

343)  A 52 year old woman with history of triple-negative, metastatic breast cancer presents to the Emergency Room with increasing shortness of breath.  She received multiple courses of chemotherapy in the past and her cancer has progressed despite initial response to chemotherapy. On examination, she is afebrile,  respiratory rate is 24/min, Blood pressure 120/70 mm Hg and Heart Rate 106/min. Breath sounds are decreased on right side of the chest and there is dullness to auscultation. A chest X-ray shows collapsed right lung and  massive right sided pleural effusion. A  thoracentesis is performed followed by thoracostomy tube is placement and about 2000 ml fluid is drained. About one houar after the procedure, the patient develops severe shortness of breath and cough with pink and foamy sputum. A pulse oximetry shows Sa02 at 86%. Which of the following most likely explains her newly developed symptoms?

A) Alveolar Hemorrhage

B) Lymphangiocarcinomatosis

C) Chylothorax due to Thoracic Duct Injury

D) Pulmonary edema

E) Acute Respiratory Distress Syndrome

Question of the Week # 343

343)  A 52 year old woman with history of triple-negative, metastatic breast cancer presents to the Emergency Room with increasing shortness of breath.  She received multiple courses of chemotherapy in the past and her cancer has progressed despite initial response to chemotherapy. On examination, she is afebrile,  respiratory rate is 24/min, Blood pressure 120/70 mm Hg and Heart Rate 106/min. Breath sounds are decreased on right side of the chest and there is dullness to auscultation. A chest X-ray shows collapsed right lung and  massive right sided pleural effusion. A  thoracentesis is performed followed by thoracostomy tube is placement and about 2000 ml fluid is drained. About one houar after the procedure, the patient develops severe shortness of breath and cough with pink and foamy sputum. A pulse oximetry shows Sa02 at 86%. Which of the following most likely explains her newly developed symptoms?

A) Alveolar Hemorrhage

B) Lymphangiocarcinomatosis

C) Chylothorax due to Thoracic Duct Injury

D) Pulmonary edema

E) Acute Respiratory Distress Syndrome

Question of the Week # 342

342) A 65 year old man presents with progressively increasing shortness of breath. He has a 100 pack year history of smoking. His past medical history is significant for coronary artery disease and congestive heart failure. He has been admitted several times in the past one year for Congestive heart failure exacerbations which resulted from his non-compliance with diet and medications. His medications include aspirin, metoprolol, enalapril, and spironolactone and tiotropium inhaler. On examination, he is afebrile with respiratory rate 24/min, pulse 106beats/min, blood pressure 140/90. Crepitations are heard at bilateral lung bases and breath sounds decreased bilaterally.  A 2D echocardiogram reveals ejection fraction at 30% . An EKG reveals changes consistent with left ventricular hypertrophy. A Chest X-ray shows moderate pleural effusions bilaterally. Which of the following is the most appropriate next step in management of pleural effusion?

A) Intravenous Furosemide

B) Tube Thoracostomy

C) Tube thoracostomy followed by Pleurodesis

D) Needle thoracentesis

E) Implantable Cardioverter-Defibrillator (ICD) placement

Question of the Week # 342

342) A 65 year old man presents with progressively increasing shortness of breath. He has a 100 pack year history of smoking. His past medical history is significant for coronary artery disease and congestive heart failure. He has been admitted several times in the past one year for Congestive heart failure exacerbations which resulted from his non-compliance with diet and medications. His medications include aspirin, metoprolol, enalapril, and spironolactone and tiotropium inhaler. On examination, he is afebrile with respiratory rate 24/min, pulse 106beats/min, blood pressure 140/90. Crepitations are heard at bilateral lung bases and breath sounds decreased bilaterally.  A 2D echocardiogram reveals ejection fraction at 30% . An EKG reveals changes consistent with left ventricular hypertrophy. A Chest X-ray shows moderate pleural effusions bilaterally. Which of the following is the most appropriate next step in management of pleural effusion?

A) Intravenous Furosemide

B) Tube Thoracostomy

C) Tube thoracostomy followed by Pleurodesis

D) Needle thoracentesis

E) Implantable Cardioverter-Defibrillator (ICD) placement